Inconsistencies between self-report and EMR for visions problems

Action Points

Eye patient self-report of symptoms and the information documented in their electronic medical record (EMR) did not always align, suggesting that symptom data in an EMR may not be comprehensive.

Note that the study suggests that the use of EMR data in research studies should be viewed cautiously.

Eye patient self-report of symptoms and the information documented in their electronic medical record (EMR) did not always align, suggesting that symptom data in an EMR may not be comprehensive, according to results from an observational study.

In more than 160 patients (more than 300 eyes), 33.8% of patients had discordant reporting of blurry vision between the Eye Symptom Questionnaire (ESQ) and EMR. Similarly, documentation was discordant for reporting glare (48.1%), pain or discomfort (26.5%), and redness (24.7%), stated Maria Woodward, MD, of the University of Michigan Medical School in Ann Arbor, and colleagues.

"Exact agreement" between a patient's survey and what appeared in their EMR occurred in only 38 of the 162 patients seen at participating ophthalmology and cornea clinics, they wrote in JAMA Ophthalmology.

"Doctors may be unaware of important symptoms and we, as physicians, should address this disconnect for the benefit of our patients," Woodward told MedPage Today. "If the EMR lacks relevant symptom information, it has implications for patient care, including communication errors and poor representation of the patient's reported problem."

In an accompanying editorial, Christina Y. Weng, MD, MBA, of Baylor College of Medicine in Houston, noted that the single-center study is, despite that limitation, one of the few to systematically study ophthalmology EMR information accuracy.

"Although the authors' findings may have limited generalizability, they draw awareness to the issue of whether EMR documentation is an accurate reflection of the patient ... With EMR here to stay, future investigation is needed to provide further insight into these important unknowns," she wrote.

Woodward's group analyzed the symptoms of 162 patients (324 eyes) who were recruited from clinics at the Kellogg Eye Center from Oct. 1, 2015 to Jan. 31, 2016. The mean age of participants was 56.6, 62.3% were female, and 84.9% were white.

Each patient completed an ESQ, based off of sources such as the NIH Toolbox, while waiting to see a physician. Eye symptom items on the ESQ were reported on a four-point Likert-type scale, including "no problem at all," "a little bit of a problem," "somewhat of a problem," or "very much of a problem," for seven questions, as well as a five-point Likert-type scale, including "none," "mild," "moderate," "severe," or "very severe," for one question (pain or discomfort).

A medical student retrospectively collected eye symptoms from the EMR corresponding with the symptoms of the ESQ. The doctors treating the patients were unaware of the surveys or that their record-keeping would be reviewed for comparison.

Overall, discordance of symptom reporting was most often characterized by positive reporting on the ESQ and lack of EMR documentation (Holm-adjusted McNemar P<.03 for seven of eight symptoms, excluding blurry vision, P=0.59).

Return visits in which the patient reported blurry vision on the ESQ had increased odds of not reporting the symptom in the EMR compared with new visits (odds ratio 5.25, 95% CI 1.69-16.30, Holm-adjusted P=0.045), the researchers reported.

"The inconsistencies imply caution for the use of EMR data in research studies. Future work should further examine why information is inconsistently reported," they wrote. "Perhaps the implementation of self-report questionnaires for symptoms in the clinical setting will mitigate the limitations of the EMR and improve the quality of documentation."

Woodward suggested that the use of a self-report system before seeing the doctor could "really change the conversation between the doctor and the patient." Rather than spending time identifying symptoms, doctors and patients could focus on discussing how to manage and cope with severe symptoms, she added.

She encouraged doctors to use these findings to help their own practices. "Integrating a questionnaire about symptoms into your clinical practice could help doctors focus more on the severity and context of those symptoms," Woodward told MedPage Today. "Information from a questionnaire could be directly documented in the medical record."

Weng acknowledged the benefits of such a practice, but pointed out several potential barriers, including the inability of certain patients to enter their data electronically because of physical limitations or technological unfamiliarity.

She offered her own thoughts for improving communication. "A potential solution would be to use templates so that the clinician would check off positive symptoms, without neglecting to inquire about other symptoms on a standard list. But these templates can result in over-documentation or inaccuracies because of 'autofill' capabilities," she stated.

Other study limitations included the potential for recall bias, and that the connection between a self-report and the medical record is missing a critical step -- the conversation between the doctor and the patient.

"It is possible that their conversation was a complete discussion of all of a patient's symptoms, but those symptoms were not captured on the medical record charting," Woodward explained.

Woodward disclosed support from the National Eye Institute. Co-authors disclosed support from the National Eye Institute, the W.K. Kellogg Foundation, and the Research to Prevent Blindness.

Two co-authors disclosed relevant relationships with the CDC and Blue Health Intelligence.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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